Post-Trauma VTE Highest in Older Kids

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Those children who developed VTE after trauma were more severely injured than those not developing VTE and more frequently required critical care and surgery.

After adjusting for other factors, the risk of VTE after trauma varied considerably across patient age and increased most dramatically at age 16 years.

The risk of venous thromboembolism (VTE) in young trauma patients increased most dramatically from ages 16 to 21, findings that could help develop standardized protocols for VTE prophylaxis in pediatric trauma, researchers noted.

VTE risk increased linearly with age, going from 0.1% in patients 12 and younger to 0.3% in those 13 to 15, then it more than doubled in patients 16 and older (0.8%), according to Elliott R. Haut, MD, from Johns Hopkins University School of Medicine, and colleagues.

A total of 63% of young patients who developed VTE needed intubation, 86% needed critical care, 89% required major surgery, and 55% had a very severe injury; but when researchers adjusted for these and other factors, older age remained a significant predictor of developing a VTE, they reported online in JAMA Surgery.

The results confirm "that age-specific differences in the risk of VTE were independent of other variables," wrote Lena M. Napolitano, MD, from the division of acute care surgery at the University of Michigan in Ann Arbor, in an invited commentary.

The overall rate of VTE (which includes pulmonary embolism and deep vein thrombosis) in the young trauma patients was 0.4% -- compared with an historical rate of about 6% for adults.

"The relative rarity of VTE in pediatric trauma patients seems to have led most surgeons to conclude that pharmacologic VTE prophylaxis is unnecessary, although practices vary considerably among adolescent trauma patients," researchers said.

Napolitano echoed the researchers when she wrote that the findings "provide the scientific basis for advancing the development of evidence-based guidelines for VTE prevention in pediatric trauma."

No such national clinical practice guidelines currently exist, although various regional protocols have been developed.

For the study, Haut and colleagues sought to identify the age at which VTE increases from the low rate seen in children to the higher rate seen in adults. They obtained data from the National Trauma Data Bank for the years 2008 to 2010 for patients ages 21 and younger who were admitted to a hospital following traumatic injury.

They identified 400,676 patients without VTE and 1,655 with VTE. There were significant differences between the two groups. Those with VTE were older, more likely to be male, be obese, have longer hospital stays, and receive blood transfusions. They were also more severely injured and more frequently required critical care and surgery.

In addition, more patients with VTE died during their stay in the hospital compared with those with no VTE (4.4% versus 1.8%). But the causes of death were unknown and could have been unrelated to VTE.

Compared with patients 12 and younger, trauma patients 13 to 15 were two times more likely to develop VTE (OR 1.96, 95% CI 1.53-2.52, P<0.001) and those 16 to 21 years old were almost four times more likely (OR 3.77, 95% CI 3.00-4.75, P<0.001).

Even among the two older age groups, those 16 and up were twice as likely to develop VTE than those 13 to 15, researchers found.

Haut and colleagues noted there was "no significant interaction ... between patient age and injury severity, suggesting that the relationship between age and VTE was not modified by injury severity."

Two subanalyses -- one examining only those patients with very severe injuries and one looking at patients treated in verified pediatric trauma centers -- showed that the relationship between age and VTE risk remained.

The study was limited by potential surveillance bias, which might have been mitigated by examining duplex ultrasonography, but only one-third of patients underwent ultrasonography. Also, it could not be determined whether patients had pharmacologic or mechanical VTE prophylaxis.

Haut receives royalties from Lippincott, Williams, & Wilkins for a book he co-authored (Avoiding Common ICU Errors) and has given expert witness testimony in various medical malpractice cases. No other disclosures were reported.

Napolitano reported she had no conflicts of interest.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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